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I’ve alluded to AMSA’s… interestingchoices regarding who they will and will not take money from (or at least, who they will claim not to take money from). Here’s the long-promised photographic evidence: the swag I collected from conference exhibitors.

Q: What’s bipedal, featherless, and quacks like a duck?

That’s right… AMSA sold them a booth at the 2011 convention, to say nothing of the smattering of naturopathic students in attendance as participants.

AMSA won’t quite take pharm money (more on that tomorrow), but they have no problem selling out to pseudoscience (that term is far too generous).

I went up to the booth and feigned ignorance as to what naturopathy is. I was told that they are “primary care physicians” who treat the “whole patient in a holistic way.” I pushed harder and harder, and for the longest time they continued to maintain that they’re “just like MD physicians.” Finally, one of their reps cracked, and poured forth the litany of quackery to which they subscribe: homeopathy, herbalism, acupuncture, therapeutic touch, and all sorts of other nonsense.

Fortunately, their written materials were more straightforward about their quackishness, though there were also some materials to recruit MD students for “integrative medicine” training at “Bastyr University“ in the Pacific Northwest (of course). Too bad they’re competing with AMSA’s own summer pseudoscience academy, whose flyers I also picked up.

For an organization that professes to support evidence-based medicine in other realms, and that ostensibly represents those students who are training to become applied scientists, this is really sad. The political gripes I might have with AMSA are one thing, but legitimizing quackery of this sort is truly beyond the pale. A poll of an unrepresentative convenience sample indicated that this is a non-partisan issue. “Open-mindedness” and “tolerance” are great, but when it comes to practices that don’t work, that mislead patients and that cast a pall on scientific medicine, organized medicine (AMSA included!) shouldn’t hesitate to take a stand.

If AMSA could be a forceful voice against pseudoscience much as they are a forceful voice for a variety of health policies with much less evidentiary support, they would be doing medicine, science, and patients a great service indeed.

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I almost forgot, at the other end of the exhibition hall was the ayurvedic quack booth. I hope these pictures speak for themselves.

Pro-union demonstrators — notably public school teachers — have flooded the state capital, Madison, to voice their displeasure with proposed cuts to pay, benefits, and collective bargaining ability. Meanwhile, a group of idealistic, enterprising physicians have set up shop to aid the protesters in their efforts. Given that these protests have been, fortunately, free from the violence wracking demonstrators in other parts of the world, these inspiring doctors have been using their special expertise for the benefit of the local protester community by writing the “sick notes” that will allow these teachers to keep their pay and jobs after having skipped work to attend the demonstrations.

As has been captured in many of the videos of the protests, these heroic physicians have been able to assess their new ”patients” in mere seconds, doubtlessly utilizing the speed-H&P skills learned by practicing medicine under the AMA-supported system of RVU-based payment.

In addition to showcasing the near-lightspeed pace at which the AMA believes outpatient medicine should be practiced, these doctors — from unlicensed resident to grizzled veteran of community practice alike — exemplify the values that will need to become more commonplace if primary care in the United States is to be revitalized.

As the voice of America’s doctors, and as the champions of primary care’s bright future as social justice advocacy, we are thrilled to see these Wisconsin physicians living up to the ideals espoused in the ITME recommendations, if not the Hippocratic Oath. The future of primary care is not in practicing medicine; it is in political agitation. These family practitioners are pioneering the way forward for their specialty. They are organizing for their community, and they are advocating for their patients’ sense of social justice, entirely unbound by the conventional problem-solving, clinical-assessment mentality that persists among primary care physicians at their own peril.

The American Medical Association stands with these brave primary care practitioners, and urges them to continue to practice primary care medicine in the best way possible. Only by following in their example can family physicians, outpatient internists, and pediatricians ”win the future” for their specialties in this environment of harsh RVU economics.

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In case you haven’t realized by now, this is not an AMA press release. It is a satire/parody of the AMA’s positions on medical education and physician supply in the context of the primary care shortage. Use of the AMA name is protected fair use. For more disclaimers, see my ”About” page.

After the initial enthusiasm of the start of medical school fades away, as excitement for the distant future is replaced with the quotidian routine of classes, lab, and review sessions, the realization finally settles in: we’re, um, expected to know all of this?

Most students at medical schools across the country respond to this challenge in the same way, living their lives by a simple, two-word credo that serves to guide their acquisition of knowledge. While I can’t say I show the same fervent devotion to it that many others do, it’s indisputably a part of medical school culture, and is certainly a useful mindset to have when it comes time to study for exams. It is in celebration of that spirit that I present to you today:

Cavalcade of Risk #123: High-Yield Edition

The Basics

Risks and probabilities are important aspects of clinical medicine. How well are medical schools teaching future doctors to process statistics and other research information from the clinical literature? What does it mean for the quality of future physicians? Jin Packard, a New York Medical College student blogging at Low-Yield Med, draws from his own experiences to argue that the level of training is “nothing shy of a disgrace.” I went one step further and called it a straight-up failure.

Darwin of Darwin’s Money brings us back to the basics, with a clear, concise explanation of how to compare sums of money across time (i.e. “present value” and “future value”). A dollar today is worth more than a dollar in 10 years. Darwin explains the “how” and “why.” Understanding this sort of calculation, and the sorts of assumptions embedded in it, is integral to understanding so much of finance, insurance, and economics. This is a great post to use to learn it, or for a quick refresher.

Health Insurance

Jeff Rose, blogging at Good Financial Cents, features a guest post summarizing the major changes to health-related Flexible Spending Accounts that took effect at the beginning of the New Year. The highlights are the need to get prescriptions for OTC drugs, restrictions on what kinds of stores can accept FSA debit cards, and higher penalties for breaking the rules. All in all, it’s become much more difficult to use FSA money to pay for over-the-counter medications and other health expenses.

Closing out an “ACO ‘orgy week’ of postings” (his words, not mine!) at the Disease Management Care Blog, Dr. Jaan Sidorov takes a look at a recent Medicare demo of these new-fangled, orgiastic Accountable Care Organizations. While, as he says, “ACOs are arguably the only good long term answer to controlling costs, reportedly by making doctors and hospitals play nice with each other and participate in downstream savings,” he wonders why “they, compared to managed care insurers, any less likely to withhold costly care.”

There are consumer protections, and then there are consumer protections. I point out an unusual pair of health policy stories from the past week: on one hand, PPACA supporters warning Republicans not to mess with the new law’s “consumer protections”; on the other hand, healthcare lawyers pointing out that for the law’s vaunted ACOs to have a decent chance of success, many existing “consumer protections” in healthcare may have to be gutted. I ask what the juxtaposition of these two implies about the moral necessity of the healthcare regulatory apparatus as a whole.

Other Insurance

Ryan at CashMoneyLife provides a quick, easy-to-digest rundown on life and viatical settlements, with attention paid to the risks and benefits for both buyers and sellers of life insurance policies in these transaction. These settlements allow life insurance policyholders to “cash out” some fraction of the policy’s face value, and investors to (maybe) make a profit when the policy pays off. Ultimately, while acknowledging that they are not evil and have their roles to play in the insurance marketplace, he concludes that these certainly “aren’t right for the majority of people out there.”

Free Money Finance touts the merits of umbrella insurance policies: they’re relatively inexpensive for the coverage that you get; and that coverage can come in really handy when one lawsuit could be all it takes to exhaust the coverage that your home and auto policies provide. As he points out, “even if your assets are low, your future earnings are probably not,” and both are fair game in a lawsuit.

Hank Stern of InsureBlog fame dissects some finance/insurance “wisdom” posted at an AOL personal finance website. He wasn’t too impressed with their list of “Seven Insurance Policies That Aren’t Worth The Money,” finding that there wasn’t much “profound wisdom to be had.” It’s worth remembering the need to keep your wits about you when reading financial advice on the Internet… or anywhere else, for that matter.

The Digerati Life makes the case that consumers should generally avoid buying the type of insurance that they’re most often offered: extended warranty programs. They’re often costly, and may duplicate coverage provided by your credit card. The proposed alternative is to save the money that would have been spent on these warranties as a personal “warranty fund” of sorts.

Non-insurance risk management

While prognostications about financial markets are dime-a-dozen, some of them still make for interesting reads. This interview with a Canadian asset manager, conducted by Arjun Rudra and posted at InvestingThesis, is one of them. The discussion touches upon prospects for gold, the likelihood that QE2 will succeed, interest rates, emerging markets, and the Canadian dollar (with a bearish outlook on most of these).

Circumcision has been shown to dramatically reduce the risk of males contracting HIV from heterosexual sex. The government of Swaziland has begun a mass circumcision campaign in the hopes of reducing HIV incidence. Jason Shafrin, the Healthcare Economist, discusses why such an effort might actually increase HIV incidence: moral hazard.

At some point afterI grow up and become a doctor, I will be sued. When that happens, I want a defence like the one described (with illustrations) by David Williams at the Health Business Blog. A patient died shortly after an operation to replace a stenosed bicusoid aortic valve. The plaintiff argued that the operation was performed improperly, and that the replacement valve chosen was of an incorrect size. The defence argued the opposite, supported by the visual aids that David has posted, and obtained a verdict in their favour.

Julie Ferguson of Workers Comp Insider sends along a wreck of a video (literally) accompanied by advice for truck operators looking to avoid mismatches between the height of their vehicle and the clearance of that rapidly-approaching underpass. Along with the usual advice to plan your route and heed signage about clearance, it’s also recommended to check in advance with local/state departments of transportation for information about low underpasses… a source of information that many people (myself included) might not think of.

Like otherenthusiasts of health policy, I spent plenty of time reading and thinking about the Wall Street Journal’s recent reporting on the RUC — the panel that decides how Medicare pays for physicians’ services. The existence of this system was news to many of my classmates, one of whom zeroed in on the hourly wage figures. By MedPAC’s calculation, radiologists would make approximately $193/hr if all of their work was paid at Medicare rates, compared to $101 for primary care physicians and $161 for surgeons.

Why, asked my classmate, should radiologists be paid so much relative to surgeons, given that the training length for diagnostic radiology and surgery is similar, and radiologists arguably play a smaller role in the care of an individual patient, face less malpractice risk (I might quibble with this, but I let it stand), and are able to work “better” hours, doing work that’s less physically demanding?

Now, the WSJ article helps to explain exactly how this situation has come about. The “market” for physicians’ services is one in which nominal and relative prices are set from above. They’ve been set in such a way that the “ROAD to happiness” starts with Radiology. (The “ROAD,” for those unfamiliar with the term, consists of Radiology, Ophthalmology, Anesthesiology, and Dermatology)

This lends itself to an interesting thought experiment. Would diagnostic radiologists fare this well under a market system? I think they would, and here’s why: I think that radiologists are medicine’s superstars, at least in an economic sense.

The reason that major-league athletes and Hollywood A-list celebrities command such high pay is not strictly because we as a society think they are individually more important than, say, an individual teacher or firefighter (or physician). It’s because these athletes and actors are in an industry where the consumer will pay a premium for the “best” (as opposed to minor league teams, indie movies, etc.), and in which many, many consumers can be reached at low marginal cost (cf. television, the internet). The athlete/actor doesn’t have to add a lot of value to a given person, but instead is compensated handsomely because he is able to add some amount of value to a lot of people who are willing to pay for it. Average class size in a public school may be 30, but most sports stadiums can fit tens of thousands, to say nothing of TV and radio audiences.

This strikes me as at least superficially similar to some aspects of diagnostic radiology. The use of medical imaging has exploded in the past 20 years, but it would be bold to claim that none of that increase has to do with the value that it adds to clinical decision-making and patient care (at least when used appropriately). And we as a society have decided that we want the best: that is to say, we want our scans read by radiologists.

What’s more, it’s entirely plausible that a diagnostic radiologist can add her full armamentarium of value to more cases per day than a physician in many other specialties. That it may take less time to read a scan doesn’t lessen the value added by having the scan read. The worth of the information to the patient is independent of the time it takes to derive it (within limits).

So, would radiologists still be on the ROAD in a market-based system of payment? The case in favour looks pretty good. Of course, the challenge facing American radiologists in my lifetime may not be justifying their value in patient care so much as justifying their value over and above their American-boarded Indian-based counterparts. Communications technology has helped make superstars of American radiologists… will it make them overpriced and obsolete as well?

There’s a central intellectual tension to be navigated during the first few months of medical school. On the one hand, there’s the desire to critically engage with the material, to think about it, and in some cases to challenge what we’re learning. On the other hand, there are some things you just have to know. All sorts of estimates abound as to the number of new terms to be learned in the first year of medical school — I’ve heard numbers in the thousands — and there comes a point where it doesn’t matter “why,” or “what more,” or “what if”… there are some things you just have to know.

This tension has so far manifested itself most clearly in the “soft” courses: the ones that try to teach ethics, professionalism, policy, “cultural competency,” “humanism,” and so on. SUMS has structured its ethics and professionalism courses quite interestingly. Small “discussion” groups get together to consider scenarios and watch media clips — some chosen from mass media, some from actual clinical practice — designed to prompt “discussion.” Invariably, these clips have been trite, facile, and chosen to allow only one “correct” answer: be nice to nurses; care about the patient; the patient is more than a disease; you need to see the patient to learn from the patient; don’t get in the attending’s way during a tricky surgery; etc.

If you’ve never been told these sorts of things before, it’s important to hear them, intuitive though they should be. Given the abundance of rhetoric from SUMS administrators about the importance of “reflection” in medical education, it’s a shame that no such opportunities are provided when considering the maxims of professionalism handed down from on high. After all, it’s the exceptions that prove* rules, and it’s the exceptions that give rise to the hardest questions, deepest thought, and ultimately the best engagement with and internalization of these norms.

Take, for instance, one of the many clips from medical shows depicting an arrogant young intern ignoring and/or being rude to nurses and other support staff. Obviously, one should not ignore or be rude to nurses or support staff. But what happens when there’s a legitimate difference of opinion? Who’s ultimately accountable for the patient’s care, and how should the decision-making and teamwork process go from there? What if someone is advocating for something that is just plain wrong? These things happen. Hiding behind a series of feel-good maxims about professionalism doesn’t prepare anyone for the tradeoffs they will encounter in the real world.

The reason I started thinking about this again was because of some remarks made by a SUMS assistant dean at our latest class meeting. As I’ve written before, at SUMS the threshold for “official professionalism incident reports” to be placed in the files that get sent to residencies can potentially be pretty low; even minor lateness to class or with administrative deadlines could potentially be punished this way.

At this meeting, the dean provided, sua sponte, an attempted justification for the breadth of this policy, and the school’s apparent willingness to make use of it (fortunately, this isn’t known to me firsthand). According to him, studies have found correlations between medical school disciplinary action and state medical board action; the biggest predictors of subsequent license sanctions for medical students are apparently” irresponsibility” and “diminished ability to improve or take criticism.”

These are bad things, and it’s not surprising that these traits in medical students would be correlated with subsequent disciplinary action as physicians. Nonetheless, part of me still wonders if this correlation might not suggest causation.

When ethics and professionalism are treated as Platonic Maxims to be taken as dictated from the Faculty Above, with no room for thought, discussion, criticism, or engagement, might not a medical student facing sanction for unprofessional conduct — particularly if that conduct is a minor instance of tardiness — become disengaged from the entire set of ideals that professionalism is supposed to represent, thereby becoming more prone to major breaches later in life?

When ethics and professionalism, instead of representing the ideals of meaningful commitment to patients, come to be associated with arbitrary-seeming exercises of power by medical school administrators or as ways of stifling legitimate discussion about the role and behaviours of physicians, might not a student learn to distrust these concepts later in life?

When students are threatened with inflated artificial sanctions in lieu of facing the actual consequences of their actions, what does it teach them about autonomy?

I usually don’t display these sorts of blatantly anti-authoritarian leanings, and I’m not asking these questions to cause a ruckus or make a point of any sort. I’m legitimately curious, and mildly concerned, about the implications of this approach to the teaching of ethics and professionalism to medical students.

These are the sorts of questions I would have loved to have asked him. I might have even started a conversation that would have been so informative as to alleviate my concerns entirely, or maybe raise them in his mind. Such potentially valuable exchanges of ideas, however, will have to wait until I’m actually permitted to initiate them.

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* – I use “prove” here in the sense of “demonstrating the existence of the rule” but also in the sense of “testing the boundaries, applicability, and viability of the rule.”

Over the past few years I’ve seen many exhortations (such as this one) to be aware of the “hidden/shadow/unofficial/cultural curriculum” of medical school. The “hidden curriculum” is that part of training that imbues us freshly-minted medical students with the often-unspoken values, norms, stereotypes (surgeon jokes, anyone?), and attitudes common to the profession. Most often, this “hidden curriculum” is said to be imparted unintentionally by professors and clinical role models.

Sometimes, however, there’s nothing hidden or unintentional about it.

Our recently-started anatomy class actually begins with a couple of weeks of embryology. Here’s one of the questions from the textbook, and its answer. To be fair, the question itself wasn’t assigned, but rather the chapter in which it was located.

Question: “A 22-year-old woman who complained of a severe “chest cold” was sent for a radiograph of her thorax. Is it advisable to examine a healthy female’s chest radiographically during the last week of her menstrual cycle? Are birth defects likely to develop in her conceptus if she happens to be pregnant?”

Answer: “Yes, a chest radiograph could be taken because the patient’s uterus and ovaries are not directly in the x-ray beam. The only radiation that the ovaries receive would be a negligible, scattered amount. Furthermore, this small amount of radiation would be highly unlikely to damage the products of conception if the patient happened to be pregnant. Most physicians, however, would defer the radiographic examination of the thorax if at all possible, because if the woman had an abnormal child, she might sue the physician, claiming that the x-rays produced the abnormality. A jury may not accept the scientific evidence of the nonteratogenicity [doesn’t cause birth defects –NWS] of low-dose radiation.” [emphasis added]

There you have it. Our first explicit lesson in defensive medicine before we even get near the cadavers in anatomy class. Some things you just can’t make up.

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I hear the answer to that question in the next edition will include a helpful reminder to make sure to run the radiograph order by the patient’s insurer’s radiology management service first.